A 50 year old male came with complaints of abdominal pain
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CASE PRESENTATION
A 50 year old male who is a labourer by occupation came to general medicine OPD with chief complaints of abdominal pain .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 yrs back then had abdominal pain in the right side of the abdomen and he is regular alcoholic. And he had aimilar complaints 4 days back .abdominal pain is gradual in onset and continuous.history of alcohol intake is present.No history of vomitings, fever,trauma,SOB.came to OPD on 2/1/2023.
PAST HISTORY
Patient had similar complaints 2 yrs ago .
patient is k/c/o diabetes mellitus since 2yrs
And Not a k/c/o hypertension, asthma, T.B, epilepsy and CAD.
No past Surgical history
No blood transfusions in the past.
FAMILY HISTORY
Not relevant
PERSONAL HISTORY
Mixed diet
Normal appetite
Adequate sleep
Bowel and bladder movements are normal
Regular alcoholic
GENERAL EXAMINATION
patient is conscious coherent and cooperative
Moderately built
Moderately nourished
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, bilateral pedal edema
VITAL SIGNS
Temperature - 97.6 F
Pulse Rate- 80 bpm
Blood pressure - 110/70 mm hg
Respiratory rate - 18
Spo2 - 98 percent
GRBS - 241 mg/dl
SYSTEMIC EXAMINATION
CVS
S1 and s2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
no dysnea
No wheeze
Position of trachea: central
Vesicular breathe sounds
ABDOMEN
Shape of the abdomen: obese
tenderness present in the left side of abdomen
No palpable mass
No organomegaly
Bowel sounds : yes
CNS
No facial asymmetry
All reflexes are normal
PROVISIONAL DIAGNOSIS
acute pancreatitis secondary to alcohol intake.
INVESTIGATIONS
TREATMENT
Inj. PAN 40MG Iv
iv fluids NS @ 100ml/hr
inj.thiamine 200mg + 100ml ns / iv
GRBS monitoring
